Utah Admin. Code R590-126-7 - Accident and Health Benefit Standards

(1)

(a) An accident and health insurance contract subject to this rule may not be delivered or issued for delivery unless it meets the required standard for the specified category in this section.

(b) This section does not preclude the issuance of a contract combining two or more categories set forth in Subsection 31A-22-605(5).

(c) Insurance coverage listed in this section shall include coverage for diabetes as required by Section 31A-22-626 and Rule R590-200, if applicable.

(2)

(a) Basic hospital expense insurance provides coverage for a period of not less than 31 days during a continuous hospital confinement for an expense incurred for treatment or service rendered as a result of an accident or sickness, and shall include at a minimum:

(i) daily hospital room and board in an amount not less than:

(A) 80% of the charge for a semiprivate room accommodation; or

(B) $100 per day;

(ii) miscellaneous hospital services and supplies, that are customarily rendered by the hospital and provided for use during a single period of confinement, in an amount not less than:

(A) 80% of the charge incurred up to at least $3,000; or

(B) ten times the daily hospital room and board benefit; and

(iii) hospital outpatient services on the day of surgery of an amount not less than:

(A) $250 for hospital services rendered within 72 hours after an injury; and

(B) $200 for x-ray and laboratory tests to the extent that a benefit for the service would have been provided if rendered to an inpatient of the hospital.

(b) Benefits may be subject to a combined deductible amount of not more than $200.

(3) Basic medical-surgical expense insurance provides coverage for expenses incurred for services rendered by a physician for treatment of an injury or sickness and shall include:

(a) surgical services in an amount not less than:

(i) what is provided on a current procedure terminology based relative value fee schedule, up to a maximum of at least $1,000 for one procedure; or

(ii) 80% of the reasonable charges;

(b) anesthesia services, consisting of the administration of medically necessary general anesthesia and related procedures in connection with a covered surgical service rendered by a physician, other than the physician or the physician assistant, performing the surgical service:

(i) in an amount not less than 80% of the reasonable charge; or

(ii) 15% of the surgical service benefit; and

(c) hospital medical services, consisting of physician services rendered to a person who is an inpatient at a hospital for treatment of sickness or injury, other than when surgical care is required, in an amount not less than:

(i) 80% of the reasonable charges; or

(ii) $100 per day.

(4) Basic hospital and medical-surgical expense insurance shall meet the requirements of Subsections (1) and (2).

(5)

(a) Hospital fixed indemnity insurance provides a daily benefit for hospital confinement on an indemnity basis and shall include:

(i) an indemnity amount of not less than $50 per day; and

(ii) coverage for at least 31 days during each one period of confinement for each insured.

(b) Benefits shall be paid regardless of other insurance.

(6)

(a) Income replacement insurance provides for periodic payments, weekly or monthly, for a specified period during the continuance of a disability resulting from either sickness or injury, or a combination of both, that:

(i) if it includes an elimination period, it is no greater than:

(A) 90 days, in the case of coverage providing a benefit of one year or less;

(B) 180 days, in the case of coverage providing a benefit of more than one year but less than two years; or

(C) 365 days in any other case; and

(ii)

(A) has a maximum period that is payable during a disability of at least six months, except in the case of a contract covering a disability arising out of pregnancy, childbirth, or miscarriage when the period for the disability may be one month; and

(B) may not be reduced because of an increase in Social Security or similar benefits during a benefit period.

(b) A contract that provides total disability or partial disability benefits may not require more than one elimination period.

(c)

(i) A contract that provides for a residual disability benefit may require a qualification period, when the insured shall be totally disabled before the residual disability benefit is payable.

(ii) The qualification period for residual benefits may be longer than the elimination period for total disability.

(d) This Subsection (6) does not apply to a contract providing business buyout coverage.

(7) Accident only insurance provides coverage, singly or in combination, for death, dismemberment, disability, or hospital and medical care caused by accident and shall include a benefit amount for:

(a) death, no less than $1,000;

(b) double dismemberment, no less than $1,000; and

(c) single dismemberment, no less than $500.

(8) Specified accident insurance provides coverage, singly or in combination, for death, dismemberment, disability, or hospital and medical care caused by a specific accident and shall include a benefit amount for:

(a) death, no less than $1,000;

(b) double dismemberment, no less than $1,000; and

(c) single dismemberment, no less than $500.

(9) Specified disease insurance, or critical illness insurance, provides coverage for the diagnosis and treatment of at least one specifically named disease.

(a) A contract covering a single specified disease or combination of specified diseases may not be sold or offered for sale other than as specified disease insurance.

(b) A contract that conditions payment upon pathological diagnosis of a covered disease shall also provide that if a pathological diagnosis is medically inappropriate, a clinical diagnosis will be accepted.

(c) A specified disease insurance contract shall provide benefits to an insured, not only for the specified disease, but also for any other condition or disease directly caused or aggravated by the specified disease or treatment of the specified disease.

(d) A specified disease insurance contract may not be more restrictive than guaranteed renewable.

(e)

(i) An enrollment form for specified disease insurance shall include a statement above the signature of the applicant that an individual is not eligible for specified disease insurance if covered by a Title XIX program, designated as Medicaid or any similar name.

(ii) The disclaimer may be combined with any other statement for which the insurer may require the applicant's signature.

(f) Payments may be conditioned upon an insured receiving medically necessary care, given in a medically appropriate location, and under a medically accepted course of diagnosis or treatment.

(g) Specified disease insurance benefits shall be paid regardless of other coverage.

(h) After the effective date of the contract, or the conclusion of an applicable probationary period, benefits shall begin with the first day of care or confinement, if such care or confinement is for a covered disease, even though the diagnosis is made at a later date.

(i) Hospice care is an optional benefit that, if offered, shall meet the following standards:

(i) benefits are payable when the attending physician provides a written statement that the insured has a life expectancy of six months or less;

(ii) a fixed-sum payment of at least $50 per day; and

(iii) a lifetime maximum benefit of at least $10,000.

(j) The following standards apply to specified disease insurance issued on an expense-incurred basis:

(i) a deductible amount may not exceed $250;

(ii) an aggregate benefit limit may not be less than $25,000;

(iii) a benefit period may not be less than three years;

(iv) services provided on an outpatient basis may be subject to a copayment that may not exceed 20% of covered services;

(v) covered services shall include:

(A) hospital room and board and any other hospital-furnished medical service or supply;

(B) treatment by, or treatment under the direction of, a physician or surgeon;

(C) private duty nursing services of a registered nurse or licensed practical nurse;

(D) x-ray, radium, chemotherapy, and other therapy procedures used in diagnosis and treatment;

(E) blood transfusions, including the administration and expense incurred for blood donors;

(F) drugs and medicines prescribed by a physician;

(G) professional ambulance for local service to or from a local hospital;

(H) the rental of any respiratory or other mechanical apparatus;

(I) braces, crutches, and wheelchairs as ordered by the physician for the treatment of the disease;

(J) emergency transportation if, in the opinion of the physician, it is necessary to transport the insured to another locality for treatment of the disease;

(K) home health care with a written prescribed plan of care;

(L) physical, speech, hearing, and occupational therapy;

(M) special equipment including a hospital bed, toilette, pulleys, wheelchairs, aspirator, chux, oxygen, surgical dressings, rubber shields, colostomy, and ileostomy appliances;

(N) prosthetic devices including wigs and artificial breasts;

(O) nursing home care for non-custodial services; and

(P) reconstructive surgery when deemed necessary by the physician.

(k) Specified disease insurance offered on a per diem basis shall include covered services for:

(i) hospital confinement benefit with a fixed-sum payment of at least $200 for each day of hospital confinement, for at least 365 days, with no deductible amount permitted;

(ii) outpatient benefit with a fixed-sum payment equal to one-half of the hospital inpatient benefit for each day of hospital or non-hospital outpatient surgery, radiation therapy, and chemotherapy, for at least 365 days of treatment;

(iii) blood and plasma benefit with a fixed-sum benefit of at least $50 per day, that includes their administration whether received as an inpatient or outpatient, for at least 365 days of treatment; and

(iv) benefits tied to confinement in a skilled nursing home or home health care, if offered:

(A) shall include a fixed-sum payment equal to:

(I) one-half of the hospital inpatient benefit for each day of skilled nursing home confinement for at least 180 days; and

(II) a fixed-sum payment equal to one-fourth of the hospital inpatient benefit for each day of home health care for at least 180 days; and

(B) may not include a restriction or limitation applied to the benefits that are more restrictive than those under Medicare.

(l) The following standards apply to specified disease insurance on a lump sum basis:

(i) benefits shall be payable as a fixed, one-time payment made within 30 days of submission to the insurer of proof of diagnosis of the specified disease, and shall be offered for sale only in even increments of $1,000; and

(ii) if coverage is advertised or otherwise represented to offer generic coverage of a disease or diseases, for example "cancer insurance" or "heart disease insurance," the minimum benefit shall be:

(A) the same dollar amount regardless of the subtype of the disease, for example lung or bone cancer; or

(B) a lesser amount for a subtype with significantly lower treatment costs, for example skin cancer, if clearly identifiable and the contract clearly differentiates each subtype and its benefits.

(10) Limited benefit health insurance coverage provides benefits less than the standards required under Subsections R590-126-7(1) through R590-126-7(9).

Notes

Utah Admin. Code R590-126-7

Adopted by Utah State Bulletin Number 2025-07, effective 3/24/2025